November 2016

There is firm evidence of a relation between type 2 diabetes (T2DM) and increased risks of cancer at various sites, but it is still unclear how different antihyperglycaemic therapies modify site-specific cancer risks. The aim of this study was to provide a complete characterization of all possible associations between individual T2DM therapies, statin use and site-specific cancers in an Austrian population. It found that patients treated with insulin or insulin secretagogues showed up to ninefold increased risks for cancers of the colon, liver, pancreas, lung and brain, but a strongly decreased risk for prostate cancer. In patients taking statins, the risks were generally decreased, with a greater risk reduction in patients not receiving antihyperglycaemic therapies. The strongest effects were observed for use of insulin and pancreatic cancer, sulfonylureas or glitazones and skin cancer as well as metformin and cancer of the prostate. The conclusion being that the use of statins offsets insulin-related cancer risks in patients with diabetes independently of sex and age. The authors posit that their data support the hyperglycaemia–cancer hypothesis. http://onlinelibrary.wiley.com/doi/10.1111/joim.12567/full

The authors of this paper note that few treatment options exist to reverse diabetic neuropathy. To investigate this, they conducted a study that compared the effect of intensive medical treatment, and islet cell transplantation for type 1 diabetes, on the change in nerve conduction velocity over six years. It found that nerve conduction velocity significantly improved post-transplant while it worsened in medically treated patients. They suggest that islet cell transplantation could be further investigated as a treatment for neuropathy in type 1 diabetes.http://www.diabetesresearchclinicalpractice.com/article/S0168-8227(16)30777-X/fulltext

The Pediatric Diabetes Consortium T1D new onset (NeOn) Study was undertaken to prospectively assess natural history and clinical outcomes in children treated at 7 American diabetes centers from the time of diagnosis. A total of 1,048 participants were enrolled in the study. It found that mean HbA1c was 7.2% (55 mmol/mol) at 3 months, followed by a progressive rise to 8.4% (68 mmol/mol) at 36 months postdiagnosis. The percentage of participants in partial remission, estimated by insulin dose adjusted HbA1c, sharply declined from 23% at 12 months to 7% at 36 months. The percentage of participants developing diabetic ketoacidosis (DKA) was 1% in the first year after diagnosis, increasing to 6% in years 2 and 3. The conclusions were that these results demonstrate the gradual decline in glycemic control due to waning residual endogenous insulin secretion with increasing duration of T1D in children and adolescents. The authors posit that the data indicates the need to translate recent advances in automated insulin delivery, new insulin analogs, and adjunctive pharmacologic agents into novel treatment strategies to maintain optimal glycemic control even early in the course of T1D.http://onlinelibrary.wiley.com/doi/10.1111/pedi.12459/abstract

This study sought to identify sets of serum peptide signatures as markers for islet autoimmunity and predictors of progression rates to clinical type 1 diabetes. A total of 41 peptides (26 proteins) were significantly different between islet autoantibody-positive and autoantibody-negative children. It discovered that two peptides were sufficient to discriminate autoantibody-positive from autoantibody-negative children. The authors say that these distinct peptide signatures, that indicate islet autoimmunity prior to the clinical manifestation of type 1 diabetes, will enable refined staging of the presymptomatic disease period.http://link.springer.com/article/10.1007/s00125-016-4150-x

This research evaluated the safety and performance of using a heart rate (HR) monitor to inform an artificial pancreas (AP) system (AP-HR) during exercise among adolescents with type 1 diabetes. Eighteen participants completed the trial. While number of hypoglycemic events during exercise and rest was not different between visits, time in hypoglycaemia was lower on AP-HR compared to standard artificial pancreas. The conclusion being that heart rate signals can safely and efficaciously be integrated in a wireless AP system to inform of physical activity. While exercise contributes to hypoglycemia among adolescents, even when using an AP system, informing the system of exercise via a HR monitor improved time in hypoglycaemia. But it did not significantly reduce the total number of hypoglycemic events, which were low in both groups.http://onlinelibrary.wiley.com/doi/10.1111/pedi.12454/abstract

This paper described the views of healthcare providers about starting insulin in patients with type 2 diabetes and looked at the specific factors that contribute to delay insulin initiation. The findings showed that there were significant differences between GPs and endocrinologists regarding the insulin initiation and that GPs felt less empowered to manage patients with diabetes. The authors suggest that specific training for professionals, and joint work with patients, could improve glycemic control.http://www.diabetesresearchclinicalpractice.com/article/S0168-8227(16)30503-4/fulltext

Prior to this investigation there was inadequate evidence to advise clinicians on the relative merits of swabbing versus tissue sampling of infected diabetic foot ulcers (DFUs). This study looked at the concordance between culture results from wound swabs and tissue samples from the same ulcer. It also asked whether or not differences in bacterial profiles from swabs and tissue samples were clinically relevant. The prognosis for patients with an infected DFU at 12 months’ follow-up was recorded. The study recruited 400 patients, and there were 299 patients in the prognosis study. The median age of the patients was 63 years and their diabetes duration was 15 years. The study reported that half of the ulcers were neuropathic and the remainder were ischaemic/neuroischaemic. Tissue sampling reported both more pathogens and more organisms overall than swabbing. Both techniques missed some organisms, with tissue sampling missing fewer than swabbing. Results from tissue sampling more frequently led to a (virtual) recommended change in therapy. Significantly more tissue than swab samples required a change in therapy. Long-term prognosis for patients with an infected foot ulcer was poor. Finally, at 12 months post-sampling, 45 (15.1%) patients had died, 52 (17.4%) patients had a lower-extremity ipsilateral amputation and 18 (6.0%) patients had revascularisation surgery.http://www.journalslibrary.nihr.ac.uk/hta/volume-20/issue-82#abstract

This is fascinating “Tomorrow’s World style” article. The exposition presents an unprecedented low cost continuous wireless monitoring system, realised through inkjet printing on a standard bandage, which can send early warnings for parameters like irregular bleeding, variations in pH levels and external pressure at wound site. In addition to the early warnings, this smart bandage concept can provide long term wound progression data to the health care providers. The smart bandage comprises a disposable part which has the inkjet printed sensors and a reusable part constituting the wireless electronics. The authors assert that this work is an important step towards futuristic wearable sensors for remote health care applications. It is so encouraging to see science taking such strides to help alleviate the sequalae of diabetes.http://www.nature.com/articles/srep28949

Diabetes (type 1 and type 2) in children and young people: diagnosis and management
NICE guideline [NG18]

This guideline from NICE covers the diagnosis and management of type 1 and type 2 diabetes in children and young people aged under 18. The guideline recommends strict targets for blood glucose control to reduce the long-term risks associated with diabetes. It is aimed at:

Healthcare professionals that care for children and young people with diabetes
Commissioners and providers of diabetes services
Children and young people with type 1 or type 2 diabetes, and their families and carers.

The National Pregnancy in Diabetes (NPID) audit measures the quality of care and outcomes for women with pre-gestational diabetes who are pregnant and aims to support quality improvement. Data is collected with consent and submitted by antenatal diabetes services in England, Wales and the Isle of Man. The NPID audit is part of the National Diabetes Audit (NDA) portfolio within the National Clinical Audit (NCA) programme and seeks to address three key questions:

Were women adequately prepared for pregnancy?
Were appropriate steps taken during pregnancy to minimise adverse outcomes to the mother?
Did any adverse outcomes occur?

The report is packed with data within the sections: Key findings and Recommendations.